Claim Initial Notification

If you wish to provide us with an initial notification of an incident that may give rise to a claim please complete the form below and email it direct to us. If you choose this medium rather than contacting us on the Emergency Claims Helpline please note that we can only acknowledge receipt when the office next reopens for work.

Please complete the form with any information at hand and send it to us:

Please fill out all fields marked with *

Company Name (if applicable):

First name: *

Last name: *

House Number or name: *

Street Name: *

Town/City: *

Post Code: *

Telephone Number:

Fax Number:

e-mail Address:

Customer Number: *

Vessel Name: *

When and Where the incident took place: *

The nature of the incident: *

Privacy policy: *

I hereby agree that any personal data disclosed by me may be saved by Pantaenius UK Ltd solely for underwriting purposes.

**Pantaenius America Ltd. is a licensed insurance agent licensed in all 50 states. It is an independent corporation incorporated under the laws of New York and is a separate and distinct entity from any entity of the Pantaenius Group.